Provider Demographics
NPI:1093573032
Name:WILLENBERG, TIFFANY (MSN, APRN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILLENBERG
Suffix:
Gender:F
Credentials:MSN, APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:855-498-6767
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:200 RIVER MARKET AVE STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-1762
Practice Address - Country:US
Practice Address - Phone:501-492-0099
Practice Address - Fax:479-968-1673
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR212640363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology